Medical record 1107036 225343396 2008-07-13T05:06:19Z SmackBot 433328 Date the maintenance tags or general fixes {{for|the New York journal published by the [[Washington Institute of Medicine]]|Medical Record (journal)}} {{Mergefrom|Medical records department|date=October 2007}} {{Nofootnotes|article|date=July 2007}} [[Image:Medical records.jpg|300px|thumb|right|A medical record folder being pulled from the records]] A '''medical record''', '''health record''', or '''medical chart''' is a systematic documentation of a [[patient]]'s [[medical history]] and [[health care|care]]. The term 'Medical record' is used both for the physical folder for each individual patient and for the body of information which comprises the total of each patient's health history. Medical records are intensely personal documents and there are many [[ethical]] and [[legal]] issues surrounding them such as the degree of third-party access and appropriate storage and disposal. Although medical records are traditionally compiled and stored by health care providers, [[personal health record]]s maintained by individual patients have become more popular in recent years. ==Purpose== The information contained in the medical record allows health care providers to provide continuity of care to individual patients. The medical record also serves as a basis for planning patient care, documenting communication between the health care provider and any other health professional contributing to the patient's care, assisting in protecting the legal interest of the patient and the health care providers responsible for the patient's care, and documenting the care and services provided to the patient. In addition, the medical record may serve as a document to [[education|educate]] [[medical school|medical students]]/[[Medical residency|resident]] physicians, to provide data for internal hospital [[clinical audit|auditing]] and [[quality control|quality assurance]], and to provide data for medical research. [[Personal health record]]s combine many of the above features with portability, thus allowing a patient to share medical records across providers and health care systems.[http://www.mckinley.uiuc.edu/clinics/medrec/medrec-faq.html]. ==Format== Traditionally, medical records have been written on paper and kept in folders. These folders are typically divided into useful sections, with new information added to each section chronologically as the patient experiences new medical issues. Active records are usually housed at the clinical site, but older records (e.g., those of the deceased) are often kept in separate facilities. The advent of [[electronic medical record]]s has not only changed the format of medical records but has increased accessibility of files. ==Contents== Although the specific content of the medical record may vary depending upon specialty and location, it usually contains the patient's identification information, the patient's health history (what the patient tells the health-care providers about his or her past and present health status), and the patient's medical examination [[medical findings|findings]] (what the health-care providers observe when the patient is examined). Other information may include lab test results; [[Medication Administration Record|medications prescribed]]; referrals ordered to health-care providers; educational materials provided; and what plans there are for further care, including patient instruction for self-care and return visits.[http://www.mckinley.uiuc.edu/clinics/medrec/medrec-faq.html] In some places, billing information is considered to be part of the medical record.[http://www.physicianspractice.com/index.cfm?fuseaction=qa.details&QA_ID=342] ===Demographics=== [[Demographic]]s include patient information that is not medical in nature. It is often information to locate the patient, including identifying numbers, addresses, and contact numbers. It may contain information about [[Race (classification of human beings)|race]] and [[religion]] as well as workplace and type of [[occupational]] information. It may also contain information regarding the patient's health insurance. It is common to also find emergency contacts located in this section of the medical chart. ===Medical history=== The [[medical history]] is a [[longitudinal]] record of what has happened to the patient since birth. It chronicles [[diseases]], major and minor [[illness]]es, as well as [[growth landmarks]]. It gives the clinician a feel for what has happened before to the patient. As a result, it may often give clues to current disease states. It includes several subsets detailed below. ;Surgical history :The surgical history is a chronicle of [[surgery]] performed for the patient. It may have dates of operations, operative [[report]]s, and/or the detailed narrative of what the [[surgery|surgeon]] did. ;Obstetric history :The [[obstetrics|obstetric]] history lists prior [[pregnancy|pregnancies]] and their outcomes. It also includes any complications of these pregnancies. ;Medications and medical allergies :The medical record may contain a summary of the patient's current and previous medications as well as any medical allergies. ;Family history :The [[family]] history lists the health status of immediate family members as well as their causes of death (if known). It may also list diseases common in the family or found only in one sex or the other. It may also include a [[pedigree chart]]. It is a valuable asset in predicting some outcomes for the patient. ;Social history :The social history is a chronicle of human interactions. It tells of the [[Interpersonal relationship|relationship]]s of the patient, his/her careers and trainings, schooling and religious training. It is helpful for the physician to know what sorts of [[community]] support the patient might expect during a major illness. It may explain the behavior of the patient in relation to illness or loss. It may also give clues as to the cause of an illness (i.e., occupational exposure to asbestos). ;Habits :Various habits which impact health, such as [[tobacco]] use, [[alcohol]] intake, [[recreational drug]] use, [[exercise]], and [[diet (nutrition)|diet]] are chronicled, often as part of the social history. This section may also include more intimate details such as sexual habits and [[sexual preference]]s. ;Immunization history :The history of [[vaccination]] is included. Any blood tests proving [[immune system|immunity]] will also be included in this section. ;Growth chart and developmental history :For children and teenagers, charts documenting growth as it compares to other children of the same age is included, so that health-care providers can follow the child's growth over time. Many diseases and social stresses can affect growth and longitudinal charting and can thus provide a clue to underlying illness. Additionally, a child's behavior (such as timing of talking, walking, etc.) as it compares to other children of the same age is documented within the medical record for much the same reasons as growth. ===Medical encounters=== Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by a [[medical specialist|specialist]] often take an exhaustive form, detailing the entirety of prior health and health care. Routine visits by a provider familiar to the patient, however, may take a shorter form such as the ''problem-oriented medical record'' (POMR), which includes a problem list of diagnoses or a "[[SOAP note|SOAP]]" method of documentation for each visit. Each encounter will generally contain the aspects below: ;[[Chief complaint]] :This is the problem that has brought the patient to see the doctor. Information on the nature and duration of the problem will be explored. ;[[History of the present illness]] :A detailed exploration of the symptoms the patient is experiencing that have caused the patient to seek medical attention. ;Physical examination :The [[physical examination]] is the recording of observations of the patient. This includes the [[Vital signs (medicine)|vital signs]] and examination of the different organ systems, especially ones that might directly be responsible for the symptoms the patient is experiencing. ;Assessment and plan :The assessment is a written summation of what are the most likely causes of the patient's current set of symptoms. The plan documents the expected course of action to address the symptoms (diagnosis, treatment, etc.). ===Orders=== Written orders by medical providers are included in the medical record. These detail the instructions given to other members of the health care team by the primary providers. ===Progress notes=== When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc. These often take the form of a [[SOAP note]] and are entered by all members of the health-care team (doctors, nurses, dietitians, clinical pharmacists, [[respiratory therapist]]s, etc). They are kept in chronological order and document the sequence of events leading to the current state of health. ===Test results=== The results of testing, such as blood tests (e.g., [[complete blood count]]) [[radiology]] examinations (e.g., [[X-ray]]s), [[pathology]] (e.g., [[biopsy]] results), or specialized testing (e.g., [[spirometry|pulmonary function testing]]) are included. Often, as in the case of [[X-ray]]s, a written report of the [[wiktionary:en:medical findings|findings]] is included in lieu of the actual film. ===Other information=== Many other items are variably kept within the medical record. Digital images of the patient, flowsheets from operations/[[intensive care unit]]s, [[informed consent]] forms, [[EKG]] tracings, outputs from medical devices (such as [[artificial pacemaker|pacemakers]]), [[chemotherapy]] protocols, and numerous other important pieces of information form part of the record depending on the patient and his or her set of illnesses/treatments. ==Administrative issues== Medical records are legal documents and are subject to the laws of the country/state in which they are produced. As such, there is great variability in rule governing production, ownership, accessibility, and destruction. === Production=== In the [[United States]], written records must be marked with the date and time and scribed with indelible pens without use of corrective paper. Errors in the record should be struck out with a single line and initialed by the author. Orders and notes must be signed by the author. Electronic versions require an [[electronic signature]]. ===Ownership=== In the [[United States]], the data contained within the medical record belongs to the patient, whereas the physical form the data takes belongs to the entity responsible for maintaining the record.{{Fact|date=July 2008}} Therefore, patients have the right to ensure that the information contained in their record is accurate. Patients can petition their health care provider to remedy factually incorrect information in their records. In the [[United Kingdom]], ownership of the [[NHS]]'s medical records belong to the [[British Department of Health|Department of Health]],<ref>{{cite journal |author=Moyle R |authorlink=Roland Moyle |title=Written Answers (Commons): SOCIAL SERVICES: Medical Records (Ownership and Storage) |journal=[[Hansard]] |month=30 November |year=1976 |volume=921 |issue=c91W |url=http://hansard.millbanksystems.com/written_answers/1976/nov/30/medical-records-ownership-and-storage |quote=Personal medical records, including X-rays, in respect of patients treated under the NHS are held to be the property of the Secretary of State. NHS hospital medical records are stored in premises designated by the appropriate health authority. Access to a patient's medical records is governed in the patient's interest by the ethics of the medical and allied professions.}}</ref> and this is taken by some to mean copyright also belongs to the authorities.<ref>{{cite web |title=Policy and Procedure For Records: Retention & Disposal |url=http://www.merseycare.nhs.uk/Library/About_Mersey_Care/Policies_Procedures/IT_Policies/Retenion%20and%20%20Disposal.pdf |format=PDF |publisher=Mersey Care NHS Trust |date=December 2003 |accessdate=2008-07-05 |quote=ownership and copyright in these records as a rule is with the NHS Trust or Health Authority, not with any individual employee or contractor.}}</ref><!-- this quote says copyright does not belong to the (eg) radiologist; that copyright does not belong to the patient is implied; does the document cite a legal basis for this claim? Also, what about medical records created in the UK but outside NHS? --> ===Accessibility=== In the [[United States]], the most basic rules governing access to a medical record dictate that only the patient and the health-care providers directly involved in delivering care have the right to view the record. The patient, however, may grant [[consent]] for any person or entity to evaluate the record. The full rules regarding access and security for medical records are set forth under the guidelines of the [[Health Insurance Portability and Accountability Act]] (HIPAA). The rules become more complicated in special situations. ;Capacity :When a patient does not have [[Capacity (law)|capacity]] (is not legally able) to make decisions regarding his or her own care, a [[legal guardian]] is designated (either through next of kin or by action of a court of law if no kin exists). Legal guardians have the ability to access the medical record in order to make medical decisions on the patient’s behalf. Those without capacity include the [[coma]]tose, minors (unless [[emancipation of minors|emancipated]]), and patients with incapacitating [[psychiatry|psychiatric]] illness or [[intoxication]]. ;Medical emergency :In the event of a medical emergency involving a non-communicative patient, consent to access medical records is assumed unless written documentation has been previously drafted (such as an [[advance directive]]) ;Research, auditing, and evaluation :Individuals involved in medical research, financial or management [[audit]]s, or program evaluation have access to the medical record. They are not allowed access to any identifying information, however. ;Risk of death or harm :Information within the record can be shared with authorities without permission when failure to do so would result in death or harm, either to the patient or to others. Information cannot be used, however, to initiate or substantiate a charge unless the previous criteria are met (i.e., information from illicit drug testing cannot be used to bring charges of possession against a patient). This rule was established in the [[United States Supreme Court]] case [[Jaffe v. Redmond]][http://biotech.law.lsu.edu/cases/medrec/42_USC_29dd-2.htm]. In the [[United Kingdom]], the [[Data Protection Act]]s and later the [[Freedom of Information Act 2000]] gave patients or their representatives the right to a copy of their record, except where information breaches confidentiality (e.g., information from another family member or where a patient has asked for information not to be disclosed to third parties) or would be harmful to the patient's wellbeing (e.g., some psychiatric assessments). Also, the legislation gives patients the right to check for any errors in their record and insist that amendments be made if required. ===Destruction=== In general, entities in possession of medical records are required to maintain those records for a given period. In the [[United Kingdom]], medical records are required for the lifetime of a patient and legally for as long as that complaint action can be brought. Generally in the UK, any recorded information should be kept legally for 7 years, but for medical records additional time must be allowed for any child to reach the age of responsibility (20 years). Medical records are required many years after a patient’s death to investigate illnesses within a community (e.g., industrial or environmental disease or even deaths at the hands of doctors committing murders, as in the [[Harold Shipman]] case).<ref>{{cite newspaper |title=Government 'Breached Ex-Soldier's Human Rights' |publisher=[[The Guardian]] |date=October 20th, 2004 |url=http://www.guardian.co.uk/military/story/0,11816,1331784,00.html}}</ref> ===Abuses=== * The [[outsourcing]] of medical record transcription and storage has the potential to violate patient-physician confidentiality by possibly allowing unaccountable persons access to patient data. * Falsification of a medical record by a medical professional is a [[felony]] in most United States jurisdictions. * Governments have often refused to disclose medical records of military personnel who have been used as experimental subjects. ==See also== * [[Medical history]] * [[Electronic medical record]] * [[Electronic health record]] * [[Hospital information system]] * [[Physical examination]] * [[Physician-patient privilege]] * [[Online Office]] ==References== {{reflist|2}} ==External links== * [http://www.nlm.nih.gov/medlineplus/personalmedicalrecords.html Personal Medical Records] from [[MedlinePlus]] * [http://www.ahima.org/ American Health Information Management Association] ** [http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_027921.hcsp?dDocName=bok1_027921 Definition of the Health Record for Legal Purposes] * [http://www.epic.org/privacy/medical/ Medical Record Privacy] - [[Electronic Privacy Information Center]] (EPIC) * [http://www.unr.edu/med/dept/OBGYN/syllabus/record.html The OB Medical Record] - [[Obstetrics]]/[[Gynecology]] Medical Student Clerkship Syllabus, [[University of Nevada, Reno]] School of Medicine * [http://recordaccess.icmcc.org/ The ICMCC portal on access to electronic medical records.] The portal includes a [http://blog.icmcc.org/ blog] to share and discuss experiences for both patients and clinicians as well as an extended overview of relevant literature. ===Organizations dealing with medical records=== * [[ASTM]] [[Continuity of Care Record]] - a patient health summary standard based upon [[XML]], the CCR can be created, read and interpreted by various [[EHR]] or [[Electronic Medical Record]] (EMR) systems, allowing easy interoperability between otherwise disparate entities. * [http://www.ahima.org/ American Health Information Management Association] [[Category:Medical informatics]] [[de:Krankengeschichte]] [[es:Historia clínica]] [[fr:Dossier médical]] [[ja:診療録]] [[ru:Медицинская карта]] [[zh:病歷]]